Shift from infectious diseases has left the U.S. more vulnerable

WASHINGTON—Having defeated the scourges of smallpox, tuberculosis and polio, U.S. Surgeon General William Stewart confidently told Congress in 1969 that it was time to "close the books on infectious diseases."

Within a few years, U.S. public health research, funding and manpower, especially at the National Institutes of Health, shifted largely from infectious diseases to chronic ones such as cancer, heart disease and stroke. Federal public hospitals that specialized in infectious diseases closed as the number of infectious disease courses at public health schools were slowly scaled back.

Decades later, as the nation prepares for a potential avian flu outbreak, those policy changes and complacency in the fight against public health threats have helped to make the United States even more vulnerable to a pandemic.

The 3,000-plus state and local health agencies that would be charged with monitoring and containing a bird flu outbreak aren't up to the challenge because of poor funding, poor staffing and a decades-long retreat from infectious disease prevention and control.

"We're not even staffed at even half the level we need to manage our day-to-day outbreaks and events in this country, let alone a challenge like pandemic flu," said Dr. Rex Archer, the director of health for Kansas City, Mo., and the president of the National Association of County Health Officials.

And despite Stewart's belief that infectious diseases were no longer a public concern, the emergence of 34 new infectious microbes since 1973 says otherwise.

"Today we face a double jeopardy from both chronic and infectious diseases, but because we forgot the public health lessons of the past, we tore down the infrastructure," that could help counter the avian flu, said Dr. Susan Blumenthal, a former U.S. assistant surgeon general.

President's Bush's call for $7.1 billion to prepare for the bird flu is a good start, but doesn't go far enough, health experts say.

"What we're failing to understand is that we need consistent long-term funding that maintains a flexible, adaptable (public health system) that can respond to all health threats," said Laurie Garrett, the Pulitzer Prize-winning author of "The Coming Plague." "We just haven't been able to hold a thought in our head long enough to look at this the right way."

With a nation on edge and lawmakers trying to avert a flu pandemic that could claim millions of U.S. lives, experts say it's time to push for that investment.

"There's a wave here and we should ride it," said Georges Benjamin, executive director of the American Public Health Association. "It's a terrible tragedy that's potentially there, but we should use it as an opportunity to address what we believe are longstanding areas of neglect in rebuilding the public health infrastructure."

The U.S. public health system is made up of state, federal and local government employees as well as private-sector professionals. Their main goal is preventing disease and disability in entire populations, rather than in individuals. States are primarily responsible for public health services, but federal funding plays an important role as well.

Along with doctors and nurses, the public health workforce includes epidemiologists, biostatisticians, nutritionists, anthropologists, lab specialists, disease investigators and engineers.

Over the last century, public health efforts such as vaccinations, improved sewage and sanitation systems and purified drinking water have helped increase life expectancy by 30 years in the United States. But as threats from childhood and contagious diseases began to decline, public money was steered into chronic diseases—and not without merit. Chronic illnesses account for the vast majority of U.S. hospitalizations, 75 percent of U.S. health care spending, and they cause more than seven out of 10 U.S. deaths.

When President Nixon declared "War on Cancer in 1971," chronic disease advocacy groups were able to increase their fundraising and found greater success lobbying for federal research and prevention dollars.

But as new research money poured in, funding for infectious disease control programs dried up, as did budgets for public health agencies. As a result, facilities and equipment became outdated, staff training waned and personnel shortages became the norm. Between 25 and 50 percent of the nation's estimated 500,000 government public health workers are expected to retire in the next five years and no replacements are in the pipeline, mainly because of low pay.

A 2003 report, "The Future of the Public's Health," by the Institute of Medicine found that the nation's "governmental public health agencies, the backbone of any public health system, still suffer from grave underfunding, political neglect and continued exclusion from the very forums in which their expertise and leadership are most needed to assure an effective public health system. This calls for urgent action."

After the Sept. 11, 2001, terrorist attacks and the anthrax scare of 2001, the government poured billions of dollars into local health agencies. The money went primarily to help detect and counter certain microbes that could be used for bio-terrorism, such as smallpox.

"But those departments have no capacity or minimal capacity to respond to garden-variety microbes, and this is the problem we're in now," said Garrett, now a senior fellow at the Center for Foreign Relations. "Developing a local lab capacity to identify anthrax spores doesn't really help you if what you're dealing with is flu."

Avian flu is one of 34 dangerous diseases, like AIDS, SARS and Ebola, to emerge worldwide since 1973—a level of discovery that's unprecedented. More people die worldwide from infectious diseases than from any other cause.

"This burst of new organisms is extremely unusual. There's probably been nothing like this since hunters became gatherers," some 10,000 years ago, said Dr. Paul Epstein, the associate director of the Center for Health and Global Environment at Harvard University. "We've had plague outbreaks before, but nothing like this."

Another 2003 report by the Institute of Medicine cited 13 factors for the flurry of diseases since 1973: human susceptibility to infection; climate and weather; ecosystem changes; microbial adaptation; human demographics and behavior; economic development and land use; increased international travel and commerce; technology and industry; poverty and social inequality; war and famine; lack of political will; bioterrorism and a breakdown of public health measures.

In the United States, those "breakdowns," such as unsanitary conditions and poor hygiene, have caused hospital-based infections to increase, the report said. About 2 million patients acquire infections in U.S. hospitals each year and about 90,000 die, according to The Centers for Disease Control and Prevention.

"There are always going to be emerging infectious diseases, and we have to have a public health infrastructure for surveillance, research, prevention, early detection and rapid response worldwide," said Blumenthal.